International Journal of Infectious Diseases
Volume 12, Issue 4 , Pages 371-373, July 2008

Recent trends in chlamydial and gonococcal conjunctivitis among neonates and adults in an Irish hospital

Department of Ophthalmology, Cork University Hospital, Wilton, Cork, Ireland

Received 10 July 2007; accepted 19 September 2007. published online 19 December 2007.

Corresponding Editor: William Cameron, Ottawa, Canada

Article Outline

Summary 

Background

Chlamydia trachomatis and Neisseria gonorrhoeae are two important and frequently overlooked causes of neonatal and adult conjunctivitis.

Objectives and methods

In order to improve primary treatment, prevention, and control of infection caused by these organisms, an analysis of all cases presenting from July 2002 to December 2006 at a major Irish regional teaching hospital was performed.

Results

There were 51 cases of conjunctivitis in total. Among neonates and adults, C. trachomatis was the most common cause of conjunctivitis. Of the adult patients, 75% were men. The annual incidence of adult chlamydial conjunctivitis increased yearly from 2002 and correlated with an overall increase in genital chlamydia infection in the region. Neonatal chlamydial conjunctivitis has an overall incidence of 0.65/1000 live births and is continuing to rise annually. In 2006, gonococcal conjunctivitis accounted for 20% of all cases of conjunctivitis caused by sexually transmitted bacteria presenting to our hospital.

Conclusions

The recent increase in the incidence of gonococcal keratitis serves to remind us that this important infection should be borne in mind when treating cases of purulent conjunctivitis. The diagnosis of chlamydial and gonococcal conjunctivitis requires a high index of suspicion and prompt treatment with systemic antibiotics.

Keywords: Chlamydia trachomatis, Neisseria gonorrhoeae, Conjunctivitis, Neonate, Adult

 

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Introduction 

Genital infection with Chlamydia trachomatis is the most common sexually transmitted bacterial infection worldwide.1 The incidence in Ireland increased over 10-fold between 1995 and 2004,2 and continues to rise on an annual basis. C. trachomatis infection of the eye may cause focal corneal scarring, neovascularization, and chronic inclusion conjunctivitis, which in the neonate may lead to otitis media and pneumonitis.3

Neisseria gonorrhoeae infection is a rare but important cause of keratoconjunctivitis, which may rapidly penetrate the intact cornea leading to endophthalmitis. Vertical transmission to the neonate may occasionally lead to meningitis, endocarditis, and septic arthritis.4

We examined the annual incidence of chlamydial and gonococcal conjunctivitis among adults and neonates presenting at a major regional teaching hospital in Ireland. The identification and treatment of these increasingly more common infections is relevant to ophthalmologists, pediatricians, and general practitioners.

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Methods 

We examined all cases of conjunctivitis caused by C. trachomatis and N. gonorrhoeae that were analyzed at Cork University Hospital between July 2002 and December 2006. Patients included inpatient and outpatient neonates under 30 days old and adults of all ages. Demographic information was retrieved from patient files and compiled on Microsoft Excel. Data concerning the regional incidence of genital chlamydia and gonococcal infections were retrieved from the local sexually transmitted infections clinic.

C. trachomatis was detected by polymerase chain reaction (PCR) using Roche Amplicor. Specimens were taken with a plastic unishaft swab and transported in prepared media at 2–8°C (Remel MicroTest™ M4RT® Transport). N. gonorrhoeae was detected by Gram staining of conjunctival secretions and subsequent culture and sensitivity testing on chocolate agar.

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Results 

Between July 2002 and December 2006 there were 51 cases of conjunctivitis caused by sexually transmitted organisms, affecting 33 adults and 18 neonates (see Figure 1). C. trachomatis was cultured in 48 cases and N. gonorrhoeae in 3 cases.

Among adults, C. trachomatis was the most common organism isolated (94%). Of the adult patients, 75% were men ranging in age from 16 to 78 years, with a mean age of 27.3 years. Women accounted for 25% of adult cases and ranged in age from 16 to 31 years, with a mean age of 21.5 years.

The annual incidence of adult chlamydial conjunctivitis increased yearly from 2002, with the greatest number of cases detected in 2005 (n=13). Data from the regional sexually transmitted infections unit also show a peak occurrence of genital chlamydia infection in 2005 with a decrease in incidence in 2006 (see Figure 2, Figure 3). There were two cases of adult gonococcal conjunctivitis cultured between 2005 and 2006. These patients were male, both under 21 years of age. In 2006, gonococcal conjunctivitis accounted for 20% of all cases of conjunctivitis caused by sexually transmitted bacteria presenting at our hospital.

There were 18 cases of neonatal conjunctivitis during the study period. C. trachomatis was cultured in 17 cases. The overall annual incidence of neonatal chlamydial conjunctivitis in this region was 0.65/1000 live births. Unlike the trends observed in the adult population, the incidence of neonatal conjunctivitis continued to rise after 2005 (see Figure 1). The average age of presentation of neonates with chlamydial conjunctivitis was 14 days. The ratio of male to female infants infected with C. trachomatis was 1:1.

There was one case of gonococcal keratoconjunctivitis in a 4-day-old female neonate giving an overall incidence of 0.04/1000 live births during the study period.

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Discussion 

Our data show that the annual incidence of adult chlamydial conjunctivitis is increasing and correlates with the annual incidence of genital chlamydial infection in the region. Young men accounted for 75% of all cases of chlamydial conjunctivitis. This contrasts with data pertaining to genital chlamydia over the same time period, which reveal that 54.2% of all cases of genital chlamydial infection occurred in female patients.

There is general consensus that ocular infection in adults results from autoinnoculation of infected genital secretions from the patient or from his/her partner.5, 6 Stenberg and Mardh showed that up to 77% of patients with symptomatic ocular infection have positive concomitant genital infection.6

Neonatal conjunctivitis has been defined as inflammation of the conjunctiva from infectious or toxic causes occurring within the first thirty days of life. C. trachomatis and N. gonorrhoeae infections are usually transmitted to the neonate by exposure to infected maternal genital flora during parturition.3

C. trachomatis is the most common sexually transmitted organism to cause neonatal conjunctivitis. The incidence in this region is similar to the incidence quoted from other developed countries, which ranges from 0.78 (Di Bartolomeo et al.7) to 8 (Hammerschlag8) per 1000 live births. Pooling data from studies published between 1977 and 1999, Rosenman et al. showed that among infants exposed to C. trachomatis at birth, the point estimate of the incidence of conjunctivitis was 15% and of pneumonia was 7%.9 The risk of a neonate acquiring gonococcal conjunctivitis following exposure is estimated to be between 30% and 50%.10

Although the ocular application of topical 0.5% erythromycin, 1.0% tetracycline, or 1.0% silver nitrate is effective in reducing the incidence of neonatal gonococcal conjunctivitis, it has been shown that all three prophylactic agents do not significantly reduce the incidence of neonatal chlamydial conjunctivitis.11 However, in areas in which the screening and treatment of maternal genital chlamydial infection is carried out, the prevalence of neonatal chlamydial conjunctivitis has decreased.12 Thus the best method of preventing neonatal chlamydial conjunctivitis is by treating infected mothers before delivery.3

Gonococcal conjunctivitis is rare in developed countries. The incidence of neonatal gonococcal conjunctivitis in our series (0.04/1000 live births) is similar to that quoted in Western Europe in the 1990s.13

C. trachomatis infection of the conjunctiva has an incubation period of 5–14 days after which the development of conjunctival erythema and scanty mucoid discharge is characteristic. Chemosis, pseudomembrane formation, and severe mucopurulent or bloody discharge may develop. When present, bloody discharge is highly specific for chlamydial infection.14 Untreated infection may result in corneal and conjunctival scarring.

Infection with N. gonorrhoeae is characterized by the development of severe purulent conjunctival discharge, a short incubation period (2–5 days), rapid corneal penetration, and endophthalmitis.

Both chlamydial and gonococcal keratoconjunctivitis in either the adult or neonate require prompt systemic treatment. Topical treatment alone is inadequate (since it will not eliminate concurrent nasopharyngeal infection) and unnecessary when systemic treatment is given. The failure rate of oral erythromycin for neonatal chlamydial conjunctivitis or pneumonia is approximately 20%. A second course of treatment may be required.15

In conclusion, C. trachomatis and N. gonorrhoeae are important causes of adult and neonatal conjunctivitis. Our data show that the increase in detected cases of chlamydial conjunctivitis was mostly among young adult men and correlated with an overall increase in genital chlamydia infection in the region. Neonatal chlamydial conjunctivitis remains endemic. A screening program directed at high risk women of child bearing age may be most effective in reducing the incidence of neonatal chlamydial conjunctivitis further. The recent increase in the incidence of gonococcal keratitis serves to remind us that this important infection should be borne in mind when treating cases of purulent conjunctivitis. The diagnosis of chlamydial and gonococcal conjunctivitis requires a high index of suspicion and prompt treatment with systemic antibiotics.

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Acknowledgements 

We wish to acknowledge Dr Bartley Cryan, Consultant Microbiologist and Mr Brendan O Reilly, Senior Medical Scientist, Department of Microbiology, Cork University Hospital, and Dr Mary Horgan, Consultant in Infectious Diseases, STD/GUM Clinic, Cork, for their assistance with data retrieval.

Conflict of interest: No conflict of interest to declare.

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References 

  1. World Health Organization. Global prevalence and incidence of selected curable sexually transmitted infections. Overview and estimates. Geneva: World Health Organization; 2001. Available at: http://www.who.int/hiv/pub/sti/who_hiv_aids_2001.02.pdf (accessed October 2007).
  2. Health Protection Surveillance Centre. The need for chlamydia screening in Ireland. Report prepared for the Scientific Advisory Committee of the Health Protection Surveillance Centre; 2005, p. 8–9. Available at: http://www.ndsc.ie/hpsc/A-Z/HepatitisHIVAIDSandSTIs/SexuallyTransmittedInfections/Chlamydia/Publications/File,1439,en.pdf (accessed October 2007).
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PII: S1201-9712(07)00197-X

doi:10.1016/j.ijid.2007.09.013

International Journal of Infectious Diseases
Volume 12, Issue 4 , Pages 371-373, July 2008

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